Lessons Learned From Market Based Approaches to MNP Distribution & Promotion IETJE REERINK 2 November 2015

 UNICEF-funded learning project on social marketing of MNPs ( )  Country programs implemented by PSI in four countries since 2013  Generating learning and evidence on market-based approaches to optimize access and use of MNPs  Local funding by UNICEF and/or other partners Project Background PAGE 2

 A TMA is a system in which all sectors - public, socially marketed and commercial - work together to deliver health choices for all population segments. The goal is to ensure that those in need are reached with the appropriate products: those in the poorest communities receive free products, those with slightly greater resources benefit from partially subsidized products, and those with a greater ability to pay may purchase their products from the commercial sector Total Market Approach PAGE 3

 Using a Market Approach to ensure sustainable access to MNPs and to encourage long-term behaviour change  Marketing mix  4 “Ps” – Product  brand & positioning – Place  multiple channels – Price  affordable pricing structure – Promotion  SBCC strategy to increase caregiver awareness about IYCF, incentivize intermediaries and to encourage the use of MNP Project Approach page 4

Madagascar  Total Population  22 million  Population living on less than $1.25 per day  76.5%  Child mortality  72 per 1000 live birth  Main cause of child mortality: Pneumonia 21% Malaria 20% Diarrhea 17% Malnutrition

Nutrition Situation  Stunting affects more than 49% of children under five (at least 2 million children) –Exclusive breastfeeding in Infants 0-6 mo : 42 % (MDG 2013) –Anemia in CU5 - 50% (DSH 2009) (across all income groups though highest among lowest SES quintiles, 57% vs 40% (2009 data) –Diversified diet for 6-23 mo - 13% ( MDG 2013)  No other MNP available on the market except limited availability of fortified ready-to- use porridge  Plumpinut for school aged children in the South

MNP Social Marketing Project Launched in May 2012 to improve IYCF in two rural and two urban areas of Madagascar through the social marketing of an MNP for home fortification. Goal: To contribute to a reduction in micronutrient deficiency (specifically iron deficiency) related morbidity and mortality in Madagascar, and to promote appropriate complementary feeding of infants and children.

Expected Results  Contribute to the reduction of iron deficiency anemia and other micronutrient deficiency levels among children 6-23 months in four districts;  Pilot and document successes and challenges for the scaling up of a sustainable social marketing strategy for distribution of the MNP among project beneficiaries in urban and rural target areas; and  Increase knowledge and awareness among caregivers of children 6-23 months about the benefits of optimal infant feeding practices.

The Pilot Areas  Distribution started in February 2013  Two rural coastal districts with high anemia levels and UNICEF presence  Social franchised clinics in Antananarivo and Fianarantsoa (urban highlands)  Targeting children 6-23 months and their caregivers  15,106 children targeted in the rural areas

Evidence-Based Decision Making  Qualitative formative study (rural) (baseline and mid term)  Pre-test of logo and packaging  Willingness to pay data (rural)  IPC and mass media impact evaluation (rural) (at two intervals)  Household quantitative study with anemia test (rural)(baseline and end line)  Provider KAP (at 2 intervals, rural and urban)  Qualitative final assessment (external)

Product  MNP containing one recommended nutrient intake (RNI) of 15 vitamins and minerals for home fortification of complementary food for children 6-23 months  Pre-testing confirmed mothers and providers’ preference for name, logo and information on the box and sachet

Price: W2P Rural priceUrban price Willing-to-pay prices are well above proposed prices

 Marketing and communication strategy developed around archetypes  Multimedia communication campaign  Point of sales materials  Promotional materials for mothers and providers/CHWs/SPs Promotion P

UNICEF - CO UNICEF – Supply Division PSI/Warehouses Public channel (BHC/SP/CHW) - rural areas – at $0.1 per box Private channel (SF clinics)– urban areas - at $0.5 per box Beneficiaries Place: Supply & Distribution Chain $

– High trial and acceptance rates at urban and community level: 46% for 1 st box; 45% the 2 nd box, 25% the 3 rd box – Positive impact on IYCF practices (11% 47% for diversification indicator) – Positive impact of IPC and mass media on dietary diversity (29.8% in non-exposed versus 52.2% in exposed groups) and MNP use – 1,230,630 sachets distributed in 12 months Some Results

Use of MNP

Impact on Breastfeeding

Impact on Anemia

Impact on ICYF Practices

Impact on Knowledge & Perception

Some Challenges…  Poor quality of product resulting in high drop out and distrust  Data reporting and quality (rural)  Urban users follow up  Small budget for communication

Lessons Learnt  Initial qualitative work was critical to get the Price and Promotion/Communication P right. The existing CBD SM system provided an ideal opportunity to integrate the MNP  Product quality and lack of routine quality testing caused serious problems that last well into the scale up  Short orientation on SM for key partners, clear assignment of roles and responsibilities at all levels and regular meetings built understanding and trust  Getting the reporting/ and monitoring system right is tricky. Regular follow up meetings with CHWs were held to reinforce messages, allow for exchange and address misunderstandings/confusion/rumors

Scale Up Phase  Full regional coverage; 1 additional region; public sector sites in Antananarivo  Pharmaceutical channel (2016); SF clinics in 9 sites  Change in execution model: NNO/MOH/PSI

 Access to MNPs? –Among the most vulnerable? –Was the product affordable and were intermediaries sufficiently motivated?  Availability of MNPs? –More consistent availability? Targeting of subsidies where free product exists? Better penetration?  Demand for and knowledge of MNPs?  Generate learning to guide replication? –In a variety of contexts with different models?  Sustainability? –Cost Recovery? Growing the total market for MNPs? Did the Project Help Improve: 24

 Consult the Program Management and Market Based Approach pages on the HF TAG website:   A short video can be found at:  Read more on the Madagascar Final Qualitative Evaluation in the Sight and Life publication Volume 28(2)2014  Ask me directly as part of the facilitated discussion on the HF TAG (November 11-13) Know More? page 25